Healthcare Provider Details

I. General information

NPI: 1063433001
Provider Name (Legal Business Name): NORTHEASTERN LABORATORY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 N CEDAR ST
HAZLETON PA
18201-5551
US

IV. Provider business mailing address

271 N CEDAR ST
HAZLETON PA
18201-5551
US

V. Phone/Fax

Practice location:
  • Phone: 570-459-0479
  • Fax: 570-459-5230
Mailing address:
  • Phone: 570-459-0479
  • Fax: 570-459-5230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number000776
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier300141
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 2
Identifier087355500
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerFEDERAL BLACK LUNG PROGRA
# 3
Identifier0009004940002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. RODNEY H ROTHWELL
Title or Position: PRESIDENT
Credential: MT(ASCP)
Phone: 570-459-0479